ATLANTA — Success in labiaplasty requires understanding of the patient's motivations and outcome goals along with good surgical technique. While these principles seem obvious, the frequency of women presenting for revision labiaplasty suggests they are too often being overlooked, says John R. Miklos, M.D.

"Avoiding complications in any surgery involves choosing the right procedure and performing it correctly. However, the first step depends on obtaining a good history to determine the patient's indication for seeking surgery and postoperative expectations, and then one must have proper training and skills," says Dr. Miklos, a private practitioner in Atlanta with fellowship training in urogynecology and laparoscopic reconstructive vaginal surgery. "Considering the number of women I see who are devastated by the results of their labiaplasty, not all surgeons are following these basic rules."

PATIENT MOTIVATIONS

Almost universally, women seeking labial reduction surgery present with protrusion of the labia minora beyond the edge of the labia majora, Dr. Miklos says. Results of a study undertaken by Dr. Miklos and his partner, Robert D. Moore, D.O., to identify patient expectations determined that 98 percent of more than 500 women having labiaplasty wanted the labia minora to be at or below the level of the labia majora. It may be surprising to some surgeons, however, that findings from a previous study (Miklos JR, Moore RD. J Sex Med. 2008;5(6):1492-1495) showed that for two-thirds of women, relief of pain, discomfort or irritation was at least part of the underlying reason why labiaplasty was being pursued, Dr. Miklos says.

"Only about one one-third of women wanted labiaplasty solely for cosmesis. For the majority, there was a functional quality of life issue involved," he says.

With the patient's anatomic goal in mind, surgeons must first determine whether it is achievable and inform the patient of their determination. In some women, the labia majora are so flat because of changes in weight and/or age-related fat atrophy that it is not possible to get the labia minora below the level of the labia majora, Dr. Miklos says.

"However, lowering of the labia minora will still relieve discomfort because the tissue will be less pedunculated. Therefore, the outcome may be acceptable to women seeking surgery for functional reasons," he says.

Dr. Miklos says it is important to be cautious about the aggressiveness of the reduction performed, taking into account whether the patient wants or is willing to have the tissue completely removed.

"One recurring problem among women who come to me for postlabiaplasty revision is a desire to have the labia minora rebuilt because the tissue was totally amputated by their previous surgeon," Dr. Miklos says.

COLORING COUNTS

Another misconception about labiaplasty surgery that leads to patient dissatisfaction is the idea that the procedure should maintain the current skin color of the labia edges. Rather, Dr. Miklos's research also shows that 98 percent of women don't want what is "natural" for their age but rather desire restoration of the pinker skin color present when they were younger.

"It is widely written throughout the literature that labiaplasty should maintain the natural skin color and border, and for that reason, the procedure is usually performed with a V-wedge resection," Dr. Miklos says. "However, to meet the expectations of the majority of patients, a linear-contouring resection should be done instead. Even then, depending on the anatomy, it is sometimes not possible to provide the desired skin color, and patients need to be told that preoperatively."

Careful technique is also critical for avoiding complications when performing a linear resection. Cutting the labia while pulling the tissue with excessive tension is one mistake that results in over-shortening to the point of near complete amputation, Dr. Miklos says.

"Though all cosmetic surgeries have their potential financial incentive, the ultimate physician reward is an elated patient with an improved quality of life. Therefore, I would caution surgeons to be slow to adapt new surgical procedures and techniques and to address patients' cosmetic labia requests with the same intensity and concern as he/she would for themselves or a family member," he says.